Introduction: Confusion is a common cause for acute admissions and is frequently misdiagnosed, resulting in increased hospital stay, morbidity and mortality. Collateral history taking is key in identifying how patients differ from their baseline. We audited collateral history taking in patients presenting with confusion to a large teaching hospital in the East Midlands in 2009 and 2012.
Change strategies: Since the initial audit there have been two main changes. The first was to introduce an acute geriatrician of the day on the emergency assessment unit. This 'front door' approach aims to apply comprehensive geriatric assessment before patients are admitted to a base ward. This facilitates early discharge and ensures geriatric services focus on the frailest patients. Secondly, the Medical Mental Health Unit has been established. This is a ward for patients with delirium and dementia, where care is provided by experienced health professionals in an environment that is adapted to reduce disorientation.
Change effects: Sixty patient notes were audited in 2009 and 41 in 2012. Despite this, more patients were documented as having dementia in the re-audit (55 and 70%, respectively). The number of collateral histories taken on the admission wards improved from 53 to 65% and from 76 to 90% once admitted to the geriatric wards. Cognitive testing on admission improved from 48 to 56%, although repetition of these assessments throughout the inpatient stay remains poor at only 10%. The use of sedation has reduced from 17 to 7%.
Conclusion: Admissions of patients with dementia are increasing; either through better diagnosis or admissions per se. Hospitals need to consider measures to meet this demand and we have discussed some ways that this may be achieved. Future work will focus on collateral history taking by other members of the multidisciplinary team, increasing geriatric inpatient capacity and promoting serial cognitive assessments.